Claims Denial Disclosure under MHPAEA (Processed In-house)(Paper)

Medical Necessity Disclosure under MHPAEA and Claims Denial Disclosure under MHPAEA

OMB: 0938-1080

IC ID: 191603

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Claims Denial Disclosure under MHPAEA (Processed In-house)(Paper)
 
No New
 
Mandatory
 
45 CFR 146.136(d)(2)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability

Health Health Care Services

 

20,300 0
   
State, Local, and Tribal Governments
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 5,675 5,675 0 0 0 0
Annual IC Time Burden (Hours) 475 475 0 0 0 0
Annual IC Cost Burden (Dollars) 3,632 3,632 0 0 0 0

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